Coalition of Oklahoma Breastfeeding Advocates Model ... Breastfeeding Polic… · Coalition of...

Coalition of Oklahoma Breastfeeding Advocates

Model Hospital Policy on Breastfeeding

For questions or more information contact: Rebecca Mannel, BS, IBCLC, RLC

Chair, Coalition of Oklahoma Breastfeeding Advocates 1200 Everett Drive , Rm 4NP4375, OU Medical Center

Oklahoma City, OK 73104 405-271-4350

[email protected]

This Model Hospital Policy on Breastfeeding has been endorsed by the following: Oklahoma State Department of Health

Oklahoma Academy of Family Physicians American College of Nurse-Midwives-Oklahoma Chapter

Association of Women’s Health, Obstetric, and Neonatal Nurses-Oklahoma Chapter Oklahoma Dietetic Association

Muscogee (Creek) Nation WIC Program WCD Enterprises, Inc: Wichita, Caddo, and Delaware Tribes

Oklahoma Healthy Mothers, Healthy Babies Coalition

M O D E L B R E A S T F E E D I N G P O L I C Y

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Purpose To promote a philosophy of maternal infant care that advocates breastfeeding and supports the normal physiological functions involved in the establishment of this maternal-infant process. To assist families choosing to breastfeed with initiating and developing a successful and satisfying experience.

his policy is based on recommendations from the most recent breastfeeding policy statements published by the Office of Women’s Health of the U.S. Department of Health and Human Services1, American Academy of Pediatrics2, American College of Obstetricians and Gynecologists3, American Academy of Family Physicians4, the American Dietetic Association6, Academy of Breastfeeding

Medicine7, World Health Organization5 and the UNICEF/WHO evidence-based “Ten Steps to Successful Breastfeeding.”5, 8, 9

The Ten Steps to Successful Breastfeeding 1) Have a written breastfeeding policy that is routinely communicated to all health care staff.

2) Train all health care staff in skills necessary to implement this policy.

3) Inform all pregnant women about the benefits and management of breastfeeding.

4) Help mothers initiate breastfeeding within 1 hour of birth.

5) Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

6) Give newborn infants no food or drink other than breast milk, unless medically indicated.

7) Practice rooming-in--allow mothers and infants to remain together--24 hours a day.

8) Encourage breastfeeding on demand.

9) Give no artificial teats or pacifiers to breastfeeding infants.

10) Foster the establishment of breastfeeding support groups and refer mothers to them upon discharge from the hospital or clinic.

T


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Policy Statements for Health Care Professionals: General

Promote, support, and protect breastfeeding enthusiastically.

Promote breastfeeding as a cultural norm and encourage family and societal support for breastfeeding.

Recognize the effect of cultural diversity on breastfeeding attitudes and practices and encourage variations, if appropriate, that effectively promote and support breastfeeding in different cultures.

Education Become knowledgeable and skilled in the anatomy, physiology and the current clinical management of

breastfeeding

Encourage development of lactation education in nursing schools and dietetic programs, in medical schools, in residency and fellowship training programs, and for practicing physicians, nurses and dietitians.

All healthcare providers involved in maternal and child health need education in human lactation.

Use every opportunity to provide age-appropriate breastfeeding education to children and adults in the medical setting and in outreach programs for student and parent groups.

Clinical Practice Work collaboratively with the obstetric, pediatric, family practice and public health communities to

ensure that women receive accurate and sufficient information throughout the perinatal period to make a fully informed decision about infant feeding.

Work collaboratively with the dental community to ensure that women are encouraged to continue to breastfeed and use good oral health practices.

Promote hospital policies and procedures that facilitate breastfeeding.

Work actively toward developing hospital policies and practices that encourage and support breastfeeding, including:

Eliminating marketing of infant formula in hospitals, including infant formula discharge packs and formula discount coupons. For more information on the elimination of infant formula in hospitals visit www.banthebags.org.

Keeping mother and infant together.

Offering appropriate infant feeding images.

Providing adequate encouragement and support of breastfeeding by all health care staff.

Encourage hospitals to provide on-going, in-depth education in human lactation for all health care staff, including physicians/clinicians.


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Have lactation support experts available at all times. Referral to International Board Certified Lactation Consultant (IBCLC) is recommended if available. To locate an IBCLC in your area visit the International Lactation Consultant Association website at www.ilca.org.

Provide effective breast pumps and private lactation areas for all breastfeeding mothers (patients and staff) in ambulatory and inpatient areas of the hospital.

Develop office practices that promote and support breastfeeding by using the guidelines and materials provided by the AAP Breastfeeding Promotion in Physicians’ Office practices program.

Become familiar with local breastfeeding resources (see attached resource page).

IBCLCs

Breastfeeding medical and nursing specialists such as certified nurse midwives

WIC Clinics and WIC Peer Counselors

Other breastfeeding educators including certified doulas

Mother-to-mother support groups such as La Leche League

Breast pump rental resources

Human Milk Banks and Local Human Milk Depots

When specialized breastfeeding services are used, the essential role of the infant’s primary health care provider within the framework of the medical home needs to be clarified for parents.

Encourage adequate, routine insurance coverage for necessary breastfeeding services and supplies, including the time required by health care providers to assess and manage breastfeeding and the cost for durable medical equipment.

Develop and maintain effective communication and coordination with other health care professionals to ensure optimal breastfeeding education, support, and counseling.

Those with breastfeeding expertise, such as maternal-child professional associations (see resource page), WIC breastfeeding coordinators and local IBCLCs can facilitate collaborative relationships and develop programs in the community and in professional organizations for support of breastfeeding.

Advise mothers to continue their breast self-examinations on a monthly basis throughout lactation and to continue to have annual clinical breast examinations by their physicians.


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Society Encourage the media to portray breastfeeding as positive and normative.

Encourage employers to provide appropriate facilities and adequate time in the workplace for breastfeeding and/or milk expression.

Encourage childcare providers to support breastfeeding and the use of expressed human milk provided by the parent.

Support the efforts of parents and the courts to encourage continuation of breastfeeding in separation and custody proceedings.

Provide counsel to adoptive mothers who decide to breastfeed through induced lactation, and refer for professional support as needed.

Encourage development and approval of governmental policies and legislation that are supportive of breastfeeding mothers and children.

Research Promote continued basic and clinical research in the field of breastfeeding.

Encourage investigators and funding agencies to pursue studies that further delineate the scientific understandings of lactation and breastfeeding that lead to improved clinical practice in this medical field.

Encourage investigators to adequately define breastfeeding in any studies and include a group of exclusively breastfed babies as a control to improve the quality of lactation research.

Policy Statements for Documentation, Monitoring and Continuing Education:

A written breastfeeding policy will be developed and communicated to all health care staff. The “name of institution” breastfeeding policy will be reviewed and updated routinely using current research as an evidence-based guide.

“Name of institution” staff will actively support breastfeeding as the preferred method of providing nutrition to infants.

A multidisciplinary, culturally appropriate team comprised of hospital administrators, physician and nursing staff, lactation consultants and specialists, nutrition staff, parents, and other appropriate staff shall be established and maintained to identify and eliminate institutional barriers to breastfeeding. On a yearly basis, this group will compile and evaluate data relevant to breastfeeding support services and formulate a plan of action to implement needed changes.

The woman’s desire to breastfeed will be documented in her permanent record.

Mothers will be encouraged to exclusively breastfeed unless medically contraindicated. The method of feeding will be documented in the permanent record of every infant.


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Exclusive breastfeeding is defined as providing breast milk as the sole source of nutrition. Exclusively breastfed babies receive no other liquids or solids.

Breastfeeding assessment, teaching, and documentation will be done on each shift and whenever possible with each staff contact with the mother.

After each feeding, staff will document information about the feeding in the infant’s permanent record. This documentation may include the latch, position, and any problems encountered. For feedings not directly observed, maternal report may be used. Every shift, a direct observation of the breastfeeding session will be performed and documented.

“Name of Institution” health professionals will attend regular educational sessions on lactation management and breastfeeding promotion to ensure that correct, current, and consistent information is provided to all mothers wishing to breastfeed.

“Name of Institution” does not accept free or below market value formula or breast milk substitutes.

Discharge bags offered to all mothers will not contain free supplies from formula manufacturers such as infant formula, coupons for formula, logos of formula companies, or literature with formula company logos, or gift certificates offering incentive rewards for using the certain formula for a period of time, as specified by the World Health Organization (WHO) Code of Marketing of Breastfeeding Substitutes.

Policy Statements for Breastfeeding Education: All pregnant women and their support persons as appropriate will be provided with information on

breastfeeding and educated on the benefits of breastfeeding, contraindications to breastfeeding, and risk of formula feeding.

Mothers will be encouraged to utilize available breastfeeding resources including classes, written materials, and video presentations, as appropriate. If clinically indicated, the clinician or nurse will make a referral to a lactation consultant or specialist.

The following will be taught to each breastfeeding mother before the mother goes home:

Proper positioning and latch-on.

Nutritive suckling and swallowing.

Milk production and release.

Frequency of feeding/feeding cues.

Expression of breast milk and use of a pump if indicated.

How to assess if infant is adequately nourished.

Reasons for contacting the clinician.


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Parents will be taught that breastfeeding infants, including cesarean-birth babies, should be fed on cue.

By discharge, most babies are breastfed 8 to 12 times each 24 hours.

Infant feeding cues (such as increased alertness or activity, mouthing, or rooting), will be used as indicators of the baby’s readiness for feeding.

Breastfeeding babies need to be breastfed at night.

Parents who, after appropriate education, choose to formula feed their infants will be provided individual instructions.

As soon as possible after delivery, mothers who are separated from their infants will be:

Instructed on how to use hand expression or a double set-up electric breast pump. Instructions will include:

Expression at least eight times per day around the clock.

Proper storage and labeling of human milk.

Kangaroo Care.

Encouragement to initiate direct breastfeeding as soon as medical conditions permit.

Before leaving the hospital, 16 breastfeeding mothers should be able to:

Position the baby correctly at the breast with no pain during the feeding.

Latch the baby to breast properly.

Recognize when the baby is swallowing milk.

Recognize that the baby should be nursed approximately 8 to 12 times every 24 hours.

Recognize age-appropriate elimination patterns.

List indications for calling a clinician.

Manually express milk from their breasts.

Prior to going home, mothers will be given the names and telephone numbers of community resources to contact for help with breastfeeding, including (the support group or resource recommended by “name of institution.”) (See Resources Page 13)


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Policy Statements for Clinical Care of Breastfeeding Mothers and Their Infants:

At birth or soon thereafter all newborns, if baby and mother are stable, will be placed skin-to-skin with the mother.

Skin-to-skin contact involves placing the baby on the mother’s bare chest.

Medically stable mother/infant couples will be given the opportunity to initiate breastfeeding within 1 hour of birth, including babies born by cesarean birth.

The administration of vitamin K and prophylactic antibiotics to prevent ophthalmia neonatorum should be delayed for the first hour after birth to allow uninterrupted mother infant contact and breastfeeding. 10

Breastfeeding mother/infant couples will be encouraged to remain together throughout their hospital stay, including at night (rooming-in). Skin-to-skin contact will be encouraged as much as possible. Routine procedures such as but not limited to hearing screening and vital signs or physical assessment should be done with little to no separation of mother and infant.

Time limits for breastfeeding on each side will be avoided.

Infants can be offered both breasts at each feeding but may be interested in feeding on only one side at a feeding during the first several days.

No supplemental water, glucose water, or formula will be given unless specifically ordered by a physician or nurse practitioner or by the mother’s documented and informed request.

Prior to non-medically indicated supplementation, mothers will be informed of the risks of supplementing.

The supplement should be fed to the baby by cup if possible and will be approximately 5 to 15 ml per feeding during the first 48 hours. 12-14

Alternative feeding methods such as syringe or spoon-feeding may also be used; however, these methods have not been proven to be effective in preserving breastfeeding.

Bottles should not be routinely placed in a breastfeeding infant’s bassinet.

The American Academy of Pediatrics recommends avoidance of pacifier use in breastfeeding babies for the first month of life to ensure successful establishment of breastfeeding. 11 Therefore, pacifiers should not be routinely given to normal full-term breastfeeding infants.

The pacifier guidelines at “name of institution” state that preterm infants in the Neonatal Intensive Care or Special Care Unit or infants with specific medical conditions may be given pacifiers for non-nutritive sucking. Ideally, these pacifiers should resemble the nipple at rest.14


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Newborns undergoing painful procedures (circumcision, for example) may be given a pacifier as a method of pain management during the procedure. The infant should not return to the mother with the pacifier.

“Name of institution” encourages “pain-free newborn care,” which may include breastfeeding during the heel stick procedure for the newborn metabolic screening tests.

Routine blood glucose monitoring of full-term, healthy appropriate for gestational age (AGA) infants is not indicated.

Assessment for clinical signs of hypoglycemia and dehydration will be ongoing. 15

Anti-lactation drugs are not recommended for any postpartum mother.

Routine use of nipple creams, ointments, or other topical preparations should be avoided unless such therapy has been indicated.

Mothers with nipple pain will be observed for latch-on techniques.

Nipple shields should not be routinely used to cover a mother’s nipple to treat latch-on problems, prevent or manage sore or cracked nipples or when a mother has flat or inverted nipples.

Bottle nipples will not be used to cover a mother’s nipple during breastfeeding.

Nipple shields should be used only in conjunction with a lactation consultation.

By 12-24 hours after birth, if the infant has not latched on or fed effectively, the mother will be instructed to begin breast massage and hand expression of colostrum into the baby’s mouth during feeding attempts.

Skin-to-skin contact will be encouraged (parents will be instructed to watch closely for feeding cues and whenever these are observed to feed the infant).

If the baby continues to feed poorly, hand expression or use of a double set-up electric breast pump will be initiated and maintained a minimum of eight times per day. Any expressed colostrum or mother’s milk will be fed to the baby by an alternative method.

The mother should be educated that she may not obtain much milk or even any milk the first few times she pumps her breasts.

Until the mother’s milk is available, a collaborative decision should be made involving the mother, nurse, and clinician regarding the need to supplement the baby.

Each day the clinicians will review the feeding plan.

Pacifiers should be avoided.

In cases of problem feeding, the lactation consultant or specialist will be consulted.10


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If the baby is still not latching on well or feeding well when going home, the feeding/pumping/supplementing plan will be reviewed in addition to routine breastfeeding instructions.

A follow-up visit or contact should occur within 24 hours.

Depending on the clinical situation it may be appropriate to delay discharge of the mother and baby to provide further breastfeeding intervention, support, and education.

All babies should be seen for follow-up within the first few days after discharge.

This visit should be with a health care provider for an evaluation of breastfeeding, a weight check, assessment of jaundice and age-appropriate elimination.

For infants discharged at less than 2 days of age (<48 hours): Follow-up at 2 to 4 days of age.

For infants discharged at more than 2 days of age (> 48 hours): Follow-up at 4 to 5 days of age.

All newborns should be seen by 2 weeks of age.2

Policy Statements for Exceptions to Breastfeeding: Breastfeeding is contraindicated in the following situations:

HIV-positive mother in developed countries.

Mother using illicit drugs (for example, cocaine, heroin) unless specifically approved by the infant’s health care provider on a case-by-case basis.

A mother taking certain medications.

Although most prescribed and over-the-counter drugs are safe for the breastfeeding infant, some medications may make it necessary to interrupt breastfeeding. These include:

Radioactive Isotopes

Antimetabolites/Chemotherapy

Small number of other medications

Mother has active, untreated tuberculosis.

Mother’s expressed milk may be fed to the baby until breastfeeding can be initiated.12

Infant has galactosemia.

Mother has active herpetic lesions on her breast(s).


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Breastfeeding can continue on the unaffected breast (the Infectious Disease Service will be consulted for problematic infectious disease issues).

Mother has varicella that is determined to be infectious to the infant.

Mother has HTLV1 (human T-cell leukemia virus type 1).

References used by “Name of Institution”:

Medications and Mothers’ Milk by Thomas Hale, (2008)17

Breastfeeding: A Guide for the Medical Profession by R.A. Lawrence and R.M. Lawrence, (2005) 18

American Academy of Pediatrics Statement on the Transfer of Drugs into Human Milk, (2001) 18

Non-Exceptions Breastfeeding is not contraindicated in the following situations:

Mothers who are hepatitis B surface antigen-positive.

Mothers who are infected with hepatitis C virus (hepatitis C virus antibody or hepatitis C virus-RNA-positive blood).

Mothers who are febrile (unless cause is a contraindication outlined in the previous section).

Mothers who have been exposed to low-level environmental chemical agents.

Mothers who are seropositive carriers of cytomegalovirus (CMV) (not recent converters if the infant is term).

Decisions about breastfeeding of very low birth weight infants (birth weight <1500 g) by mothers known to be CMV-seropositive should be made with consideration of the potential benefits of human milk versus the risk of CMV transmission.

Freezing and pasteurization can significantly decrease the CMV viral load in milk.

For the majority of newborns with jaundice and hyperbilirubinemia breastfeeding can and should be continued without interruption.

In rare instances of severe hyperbilirubinemia, some clinicians may decide to interrupt breastfeeding temporarily for a brief period though this practice is controversial.13


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Additional Considerations Breastfeeding mothers should avoid the use of alcoholic beverages.

Alcohol use can inhibit the milk release.

An occasional alcoholic drink is acceptable. Breastfeeding can be avoided for 2 hours after the drink to minimize any alcohol in the milk.

□ Tobacco smoking by mothers is not a contraindication to breastfeeding. Health professionals should advise all tobacco-using mothers to avoid smoking within the home and to make every effort to wean themselves from tobacco as rapidly as possible.

Due to the potential for compromised milk production, additional infant weight checks may be indicated.


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References Policy adapted from: The Academy of Breastfeeding Medicine Protocol #7: Model Breastfeeding Policy

1. U.S. Department of Health and Human Services: HHS Blueprint for Action on Breastfeeding. 1–31. Washington, DC, U.S. Department of Health and Human Services, Office on Women’s Health, 2000.

2. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.

3. American College of Obstetricians and Gynecologists (ACOG). Special Report from ACOG, Breastfeeding: Maternal and Infant Aspects. ACOG Clinical Review 2007 Vol.12, Issue1 (supplement).

4. The American Academy of Family Physicians. Family Physicians Supporting Breastfeeding: Breastfeeding Position Paper 2008 Available at URL: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html (accessed March 9, 2007).

5. World Health Organization, United Nations Children’s Fund: Protecting, promoting and supporting breastfeeding: The special role of maternity services (A joint WHO/UNICEF statement). Int J Gynecol Obstet31:171–183, 1990.

6. Position of the American Dietetic Association: Promoting and Supporting Breastfeeding. J Am Diet Assoc 105:810-818, 2005.

7. Academy of Breastfeeding Medicine Board of Directors. ABM Mission Statement. www.bfmed.org. 2003.

8. WHO/UNICEF Joint Statement. Meeting on Infant and Young Child Feeding. J Nurse-Midwifery25:31–38, 1980.

9. World Health Organization and United Nations Children’s Fund: Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. New York UNICEF, 1990.

10. Protocol Committee Academy of Breastfeeding Medicine, Cordes R, Howard CR: Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Newborn. www.bfmed.org. Academy of Breastfeeding Medicine, 2002.

11. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. Pediatrics Vol. 116 No. 5 November 2005, pp. 1245-1255 (doi:10.1542/peds.2005-1499).

12. Howard CR, Howard FM, Lanphear B, et al: Randomized clinical trial of pacifier use and bottle feeding or cup feeding and their effect on breastfeeding. Pediatrics 111:511-518, 2003.

13. Howard CR, de Blieck EA, ten Hoopen CB, et al: Physiologic stability of newborns during cup- and bottle feeding. Pediatrics 104:1-7, 1999.

14. Marinelli KA, Burke GS, Dodd VL: A comparison of the safety of cup feedings and bottle feedings in premature infants whose mothers intend to breastfeed. J Perinatol 21:350-355, 2001.

15. Protocol Committee Academy of Breastfeeding Medicine, Wright NE, Marinelli KA,:: Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates. www.bfmed.org. Academy of Breastfeeding Medicine, 2006.

16. Protocol Committee Academy of Breastfeeding Medicine, Gartner L, Howard C R: Clinical Protocol #2: Guidelines for Hospital Discharge of the Breastfeeding Term Infant and Mother “The Going Home Protocol.” www.bfmed.org. Academy of Breastfeeding Medicine, 2007.

17. Hale TW: Medications and Mother’s Milk, 13th ed. Amarillo, TX, Pharmasoft Medical Publishing, 2008.

18. Lawrence RA, Lawrence RM: Breastfeeding: A guide for the medical profession, 6th ed. St. Louis, Elsevier/C.V. Mosby, 2005.


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Breastfeeding Resources

Oklahoma Breastfeeding Hotline 1-877-271-MILK (6455)

Academy of Breastfeeding Medicine http://www.bfmed.org/ Agency for Healthcare Research and Quality http://www.ahrq.gov/clinic/tp/brfouttp.htm American Academy of Pediatrics http://www.aap.org/healthtopics/breastfeeding.cfm Ban the Bag – National campaign to stop formula company marketing in maternity hospitals http://www.banthebags.org Centers for Disease Control - Breastfeeding http://www.cdc.gov/breastfeeding/ Find a Lactation Consultant http://www.ilca.org/ HHeeaalltthhyy PPeeooppllee 22001100 OObbjjeeccttiivveess http://www.healthypeople.gov/document/html/volume2/16mich.htm#_Toc494699668 Human Milk Banking Association of North America, Inc. http://www.hmbana.org/ Indian Health Services Breastfeeding Site http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm International Lactation Consultant Association http://www.ilca.org/ La Leche League International http://www.lalecheleague.org/ Oklahoma - Healthy Mothers Healthy Babies Coalition http://www.oica.org/projects_and_issues/health/hm_hb/index.html Oklahoma - Maternal and Child Health Service http://www.ok.gov/health/Child_and_Family_Health/Maternal_and_Child_Health_Service/ Oklahoma - Pregnancy Risk Assessment Monitoring System (PRAMS) http://www.ok.gov/health/Child_and_Family_Health/Maternal_and_Child_Health_Service/Data_and_Evaluation/Pregnancy_Risk_Assessment_Monitoring_System_(PRAMS)/PRAMSGRAM_Archives/


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Oklahoma Turning Point - Certified Health Businesses http://www.okturningpoint.org/ Oklahoma - Oklahoma State Department of Health Breastfeeding Information and Support http://bis.health.ok.gov Oklahoma - WIC Breastfeeding Promotion and Support http://www.ok.gov/health/Child_and_Family_Health/WIC/WIC_Breastfeeding_Promotion_and_Support/index.html Strong & Healthy Oklahoma:

Guidebook http://www.ok.gov/strongandhealthy/documents/SHO%20Healthy%20ok%20Guide.pdf Community Resource Book

http://www.ok.gov/strongandhealthy/documents/Community%20Resource%20List%20-%20final%20version2.pdf

Breastfeeding Information http://www.ok.gov/strongandhealthy/Eat_Better/Breastfeeding.html

United States Breastfeeding Committee http://www.usbreastfeeding.org/ World Health Organization http://www.who.int/topics/breastfeeding/en/


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Acknowledgments

The Coalition of Oklahoma Breastfeeding Advocates would like to acknowledge the following individuals for their contribution and valuable input into the development of this Model Hospital Breastfeeding Policy:

Margaret Back, RN, IBCLC, RLC

Nancy Bacon, MS, RD/LD, CDE

Bonnie Bellah, BSW

Debi Bocar, RN, PhD, IBCLC, RLC

Dana Campbell-Sternlof

Gina L. Collins, LPN, IBCLC, RLC

Diane Lay, RD/LD

Liz Mallett

Rebecca Mannel, BS, IBCLC, RLC

Linda Miller, MEd, RN

Landon Norton, MS, RD/LD

Karen Palumbo, MEd, CCE, CBE, CD (DONA)

Rosanne Smith, RD/LD, IBCLC, RLC

Crystal Stearns, RNC, IBCLC, RLC

Anne Wade, RN, IBCLC, RLC

Funding is provided by the Oklahoma State Department of Health WIC Program

AN EQUAL OPPORTUNITY EMPLOYER

This publication was printed by the Oklahoma State Department of Health as authorized by Rocky McElvany, M.S., Interim Commissioner of Health. 600 copies were printed by Docutech in February 2009 at a cost of $870.00.

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